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Noy. 12, 2007 11 : 51AM Ki "N WAY TIRE CO. 209 242-3051 No, 6881 P. 3 <br /> VVILSON Y 11Mt c:U., 11n;. awo�(- BEET SERVICE RECORD <br /> U.S. TIRE SALES TPID 000837. 111847 <br /> d01 Wilson Way lies Wilson Way Ties Rocep #02 Connell Tiro 00s Wilson Way Tiro 421 US Torr Solea 92.7 U6 Tiro Sarei irao U6 Tiro 6.1- <br /> 221 N.Wilson Way 1575 Market St. 2211 N.Wilson Way If 13J W.Eleverrrh 6T. 2800 Yoaem/ee Blvd, f 9f 6 National Avn 6530 Franklin Blvd. <br /> blooklon,Ca.96209 9t"Irton,Ca.99P06 Sfochfon,Ca.96205 Tracy,Co.9"76 Modesto.CA.94954 Hayward,Ce.94W Baoremento,GA.M23 <br /> 209 46.0ml 209-689-3282 POB-40&uaf 209-0.35.4017 7'09.5715611 4106817.1292 9/6.3.9&22{6 <br /> CUSTOMER PO tl DATE <br /> — D <br /> PHONE VEHICLE k <br /> LICENSE a <br /> LOCATION OF SERVICE STATE ZIP CODE <br /> CUSTOMER TPID <br /> DECAL q <br /> I certify that under penalty of perjury under the lows or the State of Cellfornle that the Informalion provided above is true and correct.In addition,I em @were that falsification of <br /> this Information may result In suspension,revocation,or denial of renewal of the Waste Tire Hauler Registration pursuant to Public Resources Code section 42960 and may <br /> result In civil penalties up to$25,000 per day,per violation or administrative penalties up to$5,000 per violation per day as described In Public geeourcee Code section 42962. <br /> DRIVER NAME �O DRIVER SIGNATURE DATE O <br /> -LJ <br /> CUSTOMER VFHI(.;I I'-. INFORMATIC)t,l <br /> MAKE TRUCKITRAILER q LICENSE STATE ODOMETEFVHUB <br /> SPECIAL INSTRUCTIONS ON OFF <br /> _.........._._._.._..._......._._..._. <br /> OTY, J DESCRIPTION-OF WORK COMPLETED QTY DESC)41PTION OF WORK COMPLETED QTY DESCRIPTION OF WORK COMPLETED <br /> SERVICE CALL 11 UNT/DISMOUNT(S)ON VEHICLE DRASS VALVE STEM(S) <br /> FLEET INSPECTION NT/DISMOUNT(S)LOOSE ALUMINUM STEM(S) <br /> AIR SERVICE LOOSE MOUNT(S) VALVE STEM REBUILD(S) <br /> FLAT REPAIR(S) LOOSE DISMOUNT(S) ALLIGATOR CAP(S) <br /> REPAIR MATERIAL(S) TINE(S)BALANCED METAL VALVE CAP(S) <br /> WHEEL SWITCH(S) RECONDITIONED WHEEL(5) O RING(S) <br /> Rim <br /> QTY' SIZE MFG DESCRIPTION INISH MILES: <br /> START ILES'. <br /> "Z — fly T MMES <br /> START TIME AMq <br /> ON SITE TIME. AM PM <br /> OUT TIME: AM PM <br /> FINISH TIME AM <br /> bLOADUNT HAULER EXEMPTION IF APPLICABLE <br /> � ❑ GOVERNMENT ❑ LEA EXEMPT ❑ OTHER <br /> ❑ AGRICULTURE ❑ COMMON CARRIER/BACK HAUL <br /> LOAD TYPEMPo ROM HOLE TIRE COUNT ❑ WEIGHT IN POUNDS <br /> EXPORT TO / t ❑ VOLUME CUBIC YARDS ❑WEIGHT IN TONS <br /> I Ca <br /> rllfy that under penalty of perjury under the laws of the State of California that the information provided above is true and correct.In addition,I <br /> eo��Dolo T� am aware that falsification of this Information may result In civil penalties up to$25,000 per day,per violation or eominletrailve penalties up to <br /> $5,000 per violation per day at described In Public Resources Code section 62962. <br /> • M <br /> CUSTOMER ,DAME CUSTOMER URE DATE <br /> trona.t„ � '1 'I AA7 <br />